Physician Annual Burden for Completing the Electronic and Paper Clinical Template

Home Health Face-to-Face Encounter Clinical Templates (CMS-10564)

Documents and Forms

Document Name Document Type
Form CMS-10564 Physician Annual Burden for Completing the Electronic and Paper Clinical Template Form and Instruction
CMS-10564 Progress Note and Guidance CMS-10564. 091916 Clean version Revised HH Paper and ElectronicTemplate.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Physician Annual Burden for Completing the Electronic and Paper Clinical Template	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 485.638 42 CFR 424.22 (a)(1)(v)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10564	Progress Note and Guidance	CMS-10564. 091916 Clean version Revised HH Paper and ElectronicTemplate.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,926,420	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 20 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,926,420	2,926,420
Annual IC Time Burden (Hours)	1,220,317	1,220,317
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.